New heart guidance for an estimated 4 million tactical athletes

When the firehouse alarm sounds, cardiovascular risk starts climbing before firefighters reach the burning building, Lili Barouch of Johns Hopkins Medicine told STAT. That high-pressure moment now sits at the center of new guidance from the American College of Cardiology and American Heart Association, published in JACC and Circulation, for people whose work can make another person’s survival depend on their physical capacity.

The group calls them tactical athletes: firefighters, police officers, emergency medical responders, military personnel, pilots and astronauts. Unlike competitive athletes, they may have to move from rest to intense effort without a warm-up, while carrying heavy equipment or working in extreme heat, cold, altitude or deep water. Their careers can last for decades, and ordinary cardiovascular risks — high blood pressure, high cholesterol, obesity, type 2 diabetes and smoking — remain part of the picture. Rates of sudden cardiac arrest or death are low, the statement says, but risk rises during recruit training.

The new framework, Tactical Clinical Management, connects a person’s medical condition to the job they must perform. A fitness-for-duty decision should account not only for individual health, but also for possible effects on teammates, mission success and public safety. The statement recommends a history and physical examination for all tactical athletes. An ECG, a heart rhythm recording, should be performed in those under 40 exposed to significant cardiovascular strain or serving in mission-critical roles, and is considered reasonable for other tactical athletes.

The guidance also asks clinicians to weigh cardiomyopathies, arrhythmias, congenital heart disease, coronary artery disease, valve disease, myocarditis and anticoagulation status, alongside operational hazards such as dehydration, heat, altitude, diving and aviation. Among active-duty service members, 18% had at least one listed cardiovascular risk factor, while 24% were active smokers. For astronauts, researchers hypothesize that radiation exposure during spaceflight may speed atherosclerosis, the narrowing of arteries linked to heart attacks and strokes. Organizations should keep emergency action plans and rapid access to AEDs because screening cannot prevent every sudden cardiac arrest.

Concretely, the change is a shared way to decide whether someone can safely remain in a demanding role, move to another assignment or receive continued monitoring. It gives a clinician more than a generic sports test: the assessment must reflect what happens when an alarm sounds, a teammate goes down or rescue begins at altitude. The statement is guidance, not a guarantee of safety; its authors call for registries, improved screening strategies and cardiovascular risk models built specifically for tactical athletes.